**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 5/6/25 between 7:57 a.m. and 8:54 a.m., resident #8 was observed during breakfast. The resident was seated at a table with three other residents. The resident had fluids to drink and was noted to be coughing during the meal. The resident had a difficult time keeping food on her fork. The resident appeared to be sleeping in between bites. The resident had not received any assistance or cueing from staff. The staff were in and out of the dining room assisting residents out of the dining room. There were periods of time when there were not staff monitoring residents in the dining room. Resident #8 received cueing from a resident seated next to her. The resident would pat her on the arm and encourage her to eat. During an observation on 5/7/25 from 7:53 a.m. to 8:34 a.m., resident #8 was observed in the dining room for breakfast. The resident was approached by staff at 8:05 a.m. and asked if she wanted her food cut up. The staff member then cut up the bacon the resident had on her plate. The resident also had blue berry cake, scrambled eggs and cut up cantaloupe. The resident was having a difficult time getting the food to stay on her fork. Staff reminded her to chew her food. At 8:21 a.m., the resident was noted to be coughing while eating. At 8:25 a.m., the resident was noted to be holding food in her mouth without chewing movements. At 8:27 a.m., resident #8 was noted to be coughing. During an interview on 5/6/25 at 7:59 a.m., staff member M stated there had been a modification to resident #8's diet. Staff member M stated the resident had a swallow study done. Staff member M stated resident #8 does have difficulty with swallowing. Staff member M stated the resident started with a pureed diet. Staff member M stated staff observed the resident and her diet was advanced as she could tolerate. Staff member M stated the resident was observed each time the diet was advanced to ensure no choking occurred. During an observation on 5/7/25 at 12:27 p.m., resident #8 was assisted to eat by staff. During an interview on 5/7/25 at 1:31 p.m., staff member H stated resident #8 has had a lot of dietary changes. Staff member H stated there was always staff in the dining room. Staff member H stated the resident was to have her food cut into small pieces. Staff member H stated the resident was to be monitored during mealtime. Staff member H stated the resident received assistance with eating today. Staff member H stated there had not been any modifications of silverware. During an interview on 5/7/25 at 2:26 p.m., staff member B stated we reduced the portions of food, as the amount of food appeared to be overwhelming. Staff member B stated after the esophogram procedure the facility put the resident on a pureed diet. Staff member B stated when the resident appeared to tolerate the pureed diet, they then advanced her diet. Staff member B stated they then waited until the resident tolerated the advanced diet, then the facility advanced her diet until they reached a regular diet with cut up foods. Staff member B stated she thought the resident was doing better. Staff member B stated the staff were not to rush the resident. Review of a reportable incident to the State Survey Agency, dated 1/16/25, resident #8 was observed to choke on a piece of cauliflower. Findings, submitted on 1/22/25, showed the resident was choking and staff had to administer the Heimlich Maneuver to free the resident's airway. The resident's food was cut into smaller pieces, and the resident was monitored for complications and safety. Staff member M evaluated the resident's diet and the provider ordered a bite-sized diet. Review of a report, titled XR esophagus study, dated 1/29/25, showed resident #8 had suspected mild esophageal dysmotility noted by delayed passage of contrast with pooling in the distal one third esophagus. Review of resident #8's Progress Notes showed on 2/10/25, the resident started coughing on some cottage cheese and later vomited and had to change her top due to the incident. On 2/11/25 the resident had a choking episode and the resident stated the food she swallowed does not go all the way down and it made her cough and vomit. On 4/4/25 the resident had tolerated the pureed diet and was advanced to easy to chew food. On 4/15/25, the resident was advanced to a soft and bite sized diet. Review of resident #8's Care Plan, with an initiated date of 2/12/25, showed the resident had a decreased ability to swallow and often coughs at mealtimes. Per the swallow study, the resident does have slow swallow and pockets foods in her throat at times. She often ends up vomiting during meals when coughing often. Interventions included, move to table closer to staff when eating so she can be monitored, offer food in small portions, one at a time. Cut food into bite size portions, remind the resident to slow down when eating and to tuck her chin when swallowing, trial of pureed food, and cue the resident throughout the meal to continue eating. There were no new interventions for advancement of the resident's diet. Based on observations, interviews, and record review, the facility failed to provide the safest environment possible for 1 (#2) of 14 sampled residents. This deficient practice resulted in a resident's fall with major injury; and failed to ensure a resident with a history of choking was monitored closely by staff to ensure the resident did not choke on foods, for 1 (#8) of 14 sampled residents. Resident #8 had a choking episode which required the Heimlich Maneuver be performed and continued to cough during meals. Findings include: During an observation on 5/05/25 at 12:36 p.m., resident #2 was lying in bed, eyes were closed, and the call bell was sitting on his chest; a bruise was noted on the left jaw area; a wound was noted on the left side of the back of his head; there was no floor mat next to the bed, and the bed remote was inside the drawer of the nightstand. During an interview on 5/05/25 at 12:43 p.m., staff member J stated, I heard ten different stories about his (resident #2) fall last week, the night CNA said his (resident #2) bed was left up all the way as far as it could go, and the bed control was in the bedside drawer that night, at shift change they knew his bed was up . Staff member J did not feel comfortable stating which staff member shared the information about the bed being left in the up position. During an interview on 5/05/25 at 2:25 p.m., NF2 and NF3 stated the report they received from the facility (regarding the fall) was that he (resident #2) was playing with his bed remote, and he (resident #2) raised the bed to the highest position possible, and then fell out of bed. NF2 stated the bed remote was always in the drawer, I've never seen it (bed remote) out of the drawer except maybe once since he's been living here (2019 to present). NF2 stated they heard different versions of what happened regarding his (resident #2) fall, and was concerned, But I guess it was just an accident. During an interview on 5/05/25 at 7:19 p.m., staff member D stated he was charting at the nurse's station when resident #2 fell. Staff member D stated when he got to resident #2's room, the bed was all the way up, and the bed remote was on the floor when, normally it is in the drawer of the nightstand where he cannot reach it. Staff member D stated he made sure the bed remote was always in the drawer, especially when I see him, I make sure he doesn't have it; it's the only time he's ever had it since I started working here in June of 2024. During an interview on 5/05/25 at 7:34 p.m., staff member E stated, I was passing meds when I heard a thud, and I knew it was him (resident #2); when I got to the room, the bed was high; I think he had the bed control and was playing with it; I don't think an employee did it; the remote is normally kept over bedside table or in the drawer, I don't know how he got it. Staff member E stated, We have new people, I think he had the remote that night; I think he had the remote from whoever was in there last. Staff member E stated she did not receive education on fall prevention or were there any new fall prevention interventions initiated after resident #2's fall by her or the facility. During an observation on 5/06/25 at 8:43 a.m., a fall mat was not present in resident #2's room. During an interview on 5/06/25 at 11:06 a.m., staff member B stated the evening staff took the remote away (from resident #2) because he kept raising and lowering his bed with it. Staff member B stated they were not allowed to take the bed remote away because, He has a right to fall. During an interview on 5/06/25 at 11:21 a.m., staff member F stated CNAs and nurses know the fall prevention interventions on resident #2's care plan and kardex, I make sure they know. During an interview on 5/06/25 at 1:09 p.m., staff member K stated during evening rounds with the oncoming CNA prior to resident #2's fall, he suggested more frequent rounding because resident #2 had raised his bed with the bed remote and was trying to get up. Staff member K stated he did not take the bed remote from resident #2, and it was also the first time he had ever seen resident #2 using the bed remote. Staff member K stated NF2 had asked him questions regarding the fall, and staff member K explained he had, heard a couple of different stories and scenarios, which might have caused him (resident #2) to fall including: He raised the bed himself with the bed remote, and also a CNA left the bed up after evening cares, but he couldn't remember which CNA told him this information. During an observation on 5/06/25 at 1:25 p.m., a fall mat was present in resident #2's room. During an interview on 5/06/25 at 2:35 p.m., NF 2 stated, I don't think he could have moved his bed up and down, or be able to get to the bed remote, I've never even seen him with it, he can't even use the TV remote. Review of a facility document titled, Purposeful Post-Fall Huddle, dated 4/27/25, included with resident #2's fall investigation packet, showed: .Root Cause(S):1. Resident raising bed on own, 2. Resident confusion .Action Plan: What could be done to avoid future falls (intervention)? left blank, Care plan updated? left blank . [sic] Review of a facility document titled, Progress Notes, page 7 of 23, dated 5/1/2025, e-signed by staff member F, showed: .The following initial interventions have been put in place to prevent future falls: fall matt on floor . [sic] Review of a facility document, titled, Care Plan History, created 12/2/2019, showed: .Changes Prior to Completion of Last Review, Description: [Resident] will not sustain serious injury through the review date, Target Date: 7/1/2025, Last Revision Date: 1/10/2025, Revision By: Staff member F . Review of a facility document, titled, IDT FALL REVIEW - V 3, dated 5/1/2025, with the following participants present: staff members F, B, and A, showed: .3. Describe initial interventions to prevent future falls: fall matt on floor . [sic] Review of a facility document, titled, Clinical Care Plan Detail, no date, showed: .Focus: Resident #2 is High risk for falls r/t confusion, Gait/balance problems, Unaware of safety needs, arthritis, heart failure, edema, depression .Goals: Resident #2 will not sustain serious injury through the review date .Interventions/tasks: Fall matt to floor . [sic] Review of the facility's policy titled, Fall Risk Assessment/Prevention, CCS114, Copyright 2025 [NAME] Health [NAME], showed: . For residents at increased risk, additional safety measures individualized to the resident and situation will be identified on the plan of care and implemented by the interdisciplinary team .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for 1 (#7) of 2 residents sampled for pressure ulcers. This deficient practice was corrected in December of 2023. Findings include: Review of resident #7's Re-entry MDS, dated [DATE], showed the resident was readmitted to the facility where she has resided since 2018. On this readmission she did not have a sacral pressure ulcer. Review of resident #7's EMR diagnosis, dated 9/4/23, showed, Pressure ulcer of sacral region. Review of resident #7's [Clinic Name] wound care progress note, dated 11/6/23, showed, The pressure ulcer on the sacrum has been present for 9 weeks [August/September 2023] . According to the NPIAP staging system, the pressure ulcer is classified as Stage IV . Review of resident #7's skin and wound assessments, dated 2023 - current: - There was no weekly skin or wound assessment until 9/25/23. - There were no weekly skin assessments for the months of October 2023 or November 2023. - Weekly skin assessments occurred consistently after the initiation of the facility Wound Care PIP in December 2023. During an interview on 5/7/24 at 10:47 a.m., staff member C stated new management had started at the facility and immediately identified wound care as a concern. The QAPI team initiated a PIP in December of 2023. Staff member C stated they had identified a lack of pressure reducing mattresses and pads, as well as poor layering of linen and plastic pads under residents, as contributing factors to skin concerns. They had also identified a lack of wound documentation. Staff member C stated there had been major improvements in skin and wound care since the initiation of the PIP. Staff member C stated the residents in the facility with wounds had decreased and was currently at two residents with chronic wounds, which were also improving. There were no new resident wounds. During an interview on 5/8/24 at 11:10 a.m., staff member C stated resident #7 was up in her chair early for lunch and an observation of the wound would not be possible prior to the survey exit. Staff member C stated she did the wound measurements and communication with the facility's new medical director weekly. The pressure wound to resident #7's coccyx had shown a decrease in the measurements since December 2023 and had new skin growth around the edges. Review of a facility QAPI performance improvement plan, dated 12/26/23, showed the new management at the facility initiated a performance improvement plan on wound care processes. A root cause analysis was done. Immediate interventions included: - Pressure reduction mattresses and pads, - Change from plastic to cloth bedding protectors for better air flow to skin, - Weekly graphing of wounds, and - Wound care protocol for consistency of wound care/nutritional interventions. Review of the Wound Care Process Meeting Minutes, dated 1/26/24, showed after implementing the identified interventions one month into the plan the facility had four resident skin issues which had healed. There were no new residents with skin issues. The bath aide reported skin redness and irritation was decreased across the high risk population. Meeting frequency was shown to continue weekly with summaries on the noted changes. The target date listed was 6/23/24 and the plan status showed ongoing. Review of the new facility policy, Wound Management, dated 2/2024, showed criteria for wound assessments, progress notes, interventions, and notifications. IDT to include dietary, wound care, and physician involvement.

Based on observation, interview, and record review, the facility failed to follow transfer recommendations for 1 (#10) of 1 sampled resident. This failure led to the resident receiving a large hematoma on her leg, which caused her pain, and required treatment including temporary cessation of her anticoagulant medication, as well as not allowing her to have the leg in a dependent position, therefore unable to leave bed. Findings include: During an observation and interview on 5/9/23 at 12:03 p.m., resident #10 was sitting upright in her chair in her room, and was noted to have a large oval shaped bruise on her inner leg, below her knee. The bruise was raised and black and yellowish in color. Resident #10 stated her leg was painful and thought maybe she had gotten the injury from the Hoyer lift. Resident #10 stated she did not like the Hoyer lift because it was uncomfortable. During an interview on 5/9/23 at 2:31 p.m., resident #10 stated the bruise had come from using the sit-to-stand device, and the machine moved too fast and sucked my legs in. Resident #10 stated she probably should not have been using the sit to stand for transfers, and she was probably not strong enough to use it. During an interview on 5/9/23 at 3:15 p.m., staff member K stated she had moved resident #10 on 5/8/23 using the Hoyer lift and had given her a shower. During the shower, staff member K did not notice any bruising on resident #10's leg. Staff member K stated she had used the sit to stand device with resident #10 the previous week when transferring her. During an observation and interview on 5/10/23 at 8:30 a.m., resident #10's left lower leg bruise was significantly larger in size and very black. Resident #10 stated she had used the sit to stand device for transferring on 5/8/23 in the evening. Resident #10 had banged her leg on the device, and had not informed nursing staff of the bump, because she thought it was just another bump. Resident #10 stated she did not like the Hoyer lift as it scared her. Resident #10 stated she had to go the emergency room to have the bruise evaluated, but they did not find any fractures. During an interview on 5/10/23 at 11:56 a.m., staff member B stated if physical therapy had evaluated resident #10 as needing a Hoyer lift for transfers, and the care plan showed resident #10 needed a Hoyer lift for transfers, then the resident should be only using a Hoyer lift for transfers. Staff member B stated the facility had even ordered special slings for resident #10 to use. Staff member B stated resident #10 was upset staff would not let her get out of bed due to having to keep her leg elevated. Review of resident #10's nursing progress notes, dated 5/9/23 and 5/10/23, showed: - 5/9/23 12:27, Resident LLE with 18cm ecchymotic area tender to the touch, dark purple with pink center. - 5/10/23 00:00, resident (complains of) pain in LLE, area is approx 20 cm in length and 13-14cm wide dark purple in color and swollen. - 5/10/23 03:35, area has grown since midnight. Approx 22 cm in length towards the ankle area and 15-16 cm wide. Also several large fluid filled blisters have appeared .transferred to ER. [sic] Review of the Emergency Department visit for resident #10, dated 5/10/23 at 5:32 a.m., showed, You were seen today for: Contusion of left lower leg, Anticoagulant long-term use, traumatic ecchymosis of left lower leg. Activity Restrictions .Elevate left lower leg at or above heart level, this will be necessary until resolved .Hold Xarelto. Review of resident #10's Physical Therapy evaluation, dated 4/5/23, showed, Assessment: Hoyer style lift is indicated . Review of resident #10's care plan, revised 4/5/23, showed, I will use the Hoyer lift for my transfers.